Trazodone 50mg for Insomnia: Not Recommended
The American Academy of Sleep Medicine explicitly recommends against using trazodone 50mg for the treatment of sleep onset or sleep maintenance insomnia in adults. 1
Why Trazodone 50mg Should Not Be Used
Lack of Clinically Meaningful Efficacy
- The single high-quality trial of trazodone 50mg showed only modest improvements that failed to reach clinical significance thresholds for any sleep parameter 1:
- Sleep latency reduced by only 10.2 minutes (below clinical threshold) 1
- Total sleep time increased by only 21.8 minutes (clinically insignificant) 1
- Wake after sleep onset reduced by only 7.7 minutes (below threshold) 1
- No significant improvement in subjective sleep quality 1
- Number of awakenings reduced by only 0.4 (below the 0.5 threshold) 1
Harms Outweigh Benefits
- 75% of trazodone users experienced adverse events compared to 65.4% with placebo 1
- Headache occurred in 30% (versus 19% placebo) 1
- Somnolence occurred in 23% (versus 8% placebo) 1
- The guideline explicitly states that harms potentially outweigh benefits given the absence of demonstrated efficacy 1
Additional Safety Concerns
- Daytime cognitive impairments including short-term memory deficits, impaired verbal learning, and equilibrium problems 2
- Psychomotor impairment and muscle endurance reduction 2
- Particularly concerning for elderly patients due to dizziness, sedation, and fall risk 3, 4
- Rare but serious risk of priapism leading to treatment discontinuation 3
What You Should Use Instead
First-Line Treatment
- Cognitive Behavioral Therapy for Insomnia (CBT-I) is the recommended first-line treatment 3
Second-Line Pharmacologic Options (if CBT-I fails or unavailable)
For both sleep onset AND maintenance:
For sleep onset only:
For sleep maintenance only:
When Trazodone Might Be Considered (Third-Line Only)
Trazodone should only be considered as a third-line agent after benzodiazepine receptor agonists and ramelteon have failed, and specifically when 3:
- Comorbid depression is present (though 50mg is inadequate for treating major depression and would require higher doses) 3
- It can be used in combination with a full-dose antidepressant for patients with both depression and insomnia 3
Common Pitfall to Avoid
Despite trazodone being the second most commonly prescribed medication for insomnia in clinical practice 5, 4, this widespread use is not supported by evidence and reflects a disconnect between prescribing patterns and guideline recommendations 1, 6. The perception of trazodone as a "safer" sleep agent is not justified by the data 1.
Bottom Line
Switch to an evidence-based alternative such as eszopiclone, zolpidem, or temazepam if pharmacologic treatment is needed, or preferably refer for CBT-I 1, 3. The 50mg dose of trazodone you're currently taking has been specifically studied and found to provide no clinically meaningful benefit while causing significant side effects 1.